The accuracy of ultrasound in the diagnosis of breast diseases

The study was intended to evaluate the role of ultrasound as diagnostic technique in the diagnosis of breast diseases, comparing it to the conventional and widely used technique i.e mammography ,FNAC and histopathology. THE breast diseases were divided according to their clinical and ultrasound criteria into simple cyst(10), galactocele (3), fibro adenoma (64), carcinoma (36), duct ectasia (6), abscess (3), mammary dysplasia (25) , and undetermined cases (3). All those patients were subjected for pathological confirmation by needle aspiration cytology in (80) and/or excisional biopsy in 110 patients .Twelve patients refuse FNAC (18%). The age of the patients ranged from 15-80 years with a mean of 40 years .One hundred and fourteen(76), patients had benign lesions and 36 cases of them (24%) had malignant lesions. For cystic lesions like simple cyst, abscesses , and cystic changes of mammary dysplasia , the study shows 100% sensitivity , specificity and accuracy. For FNAC , the sensitivity , specificity, and accuracy were 91% 92% respectively. For carcinoma of the breast , thee sensitivity , specificity and accuracy were 86.7% , 91%. And 90% respectively ,which is less because of some overlap of the ultrasonic criteria of benign and malignant lesions .The sensitivity ,specificity and accuracy of ultrasound is high, especially in benign lesions . therefore ultrasound is an accurate , safe , and non-invasive technique for diagnosis of breast diseases in addition to be without danger of radiation, especially for young patients less than 35 years of age.


Introduction
The accurate diagnosis of breast lesion without resort to formal biopsy is highly desirable both for patients who can be quickly reassured or counseled and clinician who con reduce the unnecessary surgery.
Recently ,the less traumatic technique of aspiration cytology long accepted abroad has been gaining in popularity. Several centers well now make affirm diagnosis of malignancy on appositive cytology alone ,or as a part of a triple assessment.
The diagnosis of breast cancer is primarily based on xray mammography .
under optimal conditions ,a sensitivity of approximately 90% can be achieved. When strict criteria are observed for additional use of ultrasound the sensitivity can be increased to about 98%. In addition the differential diagnosis between benign and malignant lesion can be improved and the rate of biopsy due false-positive mammography can be reduced. Therefore ultrasound is indicated in the following conditions. 1-The palpable mass:-cystic or solid. 2-Whether are one or more circumscribed masses seen on mammogram to determine if they are cystic or solid. 3-The dense breast. 4-Patients under 35 years of age. 5-There is palpable mass that cannot be placed on mammographic film or that is too deep for assessment of chest wall involvement mammographically 10 . 6-Evaluation of indeterminate lesions on mammography 13 . 7-Patient has had breast augmentation surgery and has a palpable abnormality not completely evaluated by mammography alone. 8-A clinically non-palpable mass seen by mammography (occult mass) 9-Localization of occult lesions preoperative localization by insertion of a hook wire or needle under ultrasound guide. 10-In pregnant and lactating patients. 11-For fine needle aspiration cytology and cyst aspiration. 12-Detection of lymph node enlargement (number and size).

Patient and method
The study was intended to evaluate the role of ultrasound as diagnostic technique in the diagnosis of breast disease comparing it to the conventional and widely used technique i.e. mammography ,FNAC ,and histopathology .
All those patients were subjected for pathological confirmation by needle aspiration cytology in(80) and/or excisional biopsy in (110) patients. Twelve patients refused FNAC(18%) . The age of the patients ranged from 15-80 years with a mean age of 40 years . One hundred and malignant lesions .For cystic lesions like simple cyst ,abscesses and cystic changes of mammary dysplasia , the study shows 100% sensitivity, specificity and accuracy .for FNAC ,the sensitivity , specificity , and accuracy were 91% and 92% respectively. For carcinoma of the breast , the sensitivity , specificity , and accuracy were86.7% , 91%, and 90% respectively , which is less because of some overlap of ultrasonic criteria of benign and malignant lesions . The sensitivity , specificity , and accuracy of ultrasound is high ,in benign lesions , therefore ultrasound is accurate , safe and non-invasive technique for diagnosis of breast diseases in addition to be without dangers of radiation , especially for patients less than 35 years of age. Results Total number of hundred fifty patients with various types of breast disease or lesions were examined by ultrasound . Of 150 pathologically confirmed cases , 30 cases had fibro adenoma , 25 had mammary dysplasia , 19 with breast cyst , 8 with duct actasia ,3 with galactocele ,4 with breast abscess , 4 with chronic inflammation , and 2 patients had fat necrosis.
The age distribution of all cases shown in  The anatomical distribution of breast diseases is shown in table (3).
Most of the breast diseases are located in the left dreast65.3% , followed by right breast 33.3% , and bilateral in 1.4% The location of breast masses in the breast shown in table (4).the UOQ 40% , of total and60.9% of malignant diseases , followed by UIQ .

Discussion
Ultrasonography of the breast is an essential technique in the diagnosis of mammary disease similar to mammography and fine needle aspiration .It is extremely reliable tool in differentiating cystic from solid breast lesions. High resolution ultrasonic scanning permits solid tumor of the breast as small as 5mm. and cystic lesions of 2mm in diameter to be detected 15 palpable mass of the breast are most suitable for sonographical examination. The age distribution on this series indicates two peaks of malignancy , the first one is between 30-44 years(44.7%) , and the second one is between 65-80 years.
The commonest presenting symptoms was breast lump without pain or other complaining, and this was true in about2/3 rd of patients (65.4%) , while lump associated with pain seen in 15.3%.Breast pain was present only in7.3%of the patients. The majority of malignant breast masses were located in UOQ of breast 61.2%of the patients Sonographic diagnosis of breast cyst can be made with a very high accuracy , and sonography alone is sufficient to establish reliable diagnosis of a pure simple cyst. In cystic lesions in differentiating cystic from solid masses of the breast our data of 100% accuracy rate for sonographic diagnosis is in full agreement with the literatures. In benign breast diseases , sonography is of value in areas of varying radiologic density .It can be more ready identify the nature of such density and it has the additional advantage of being able to exclude circumscribed mass lesion in areas clinically nodular , and radiologicaly dense . So in benign breast disease ,the ultrasound provide diagnosis in 3 out of 4 patients with uncertain diagnosis in mammography , which were radiologicaly hidden by breast density or un suitable sited for x-ray examination like extreme medial side of the breast. The image quality and diagnostic reliability strongly depend on sonogrphic equipment and the operator. In our study, the accuracy rate in the diagnosis of fibro adenoma was 92% .Fleisher et al , reported accuracy rate of 89% using (5-7mhz)transducers 27 and Nobushige et al reported accuracy rate of 93% using (7.5mhz)transducers 28 . Pregnant or lactating patients should be ideally examined sonographically , since it is non-invasive test .Lactating breast a problem for mammography examination as it usually causes a white-out appearance with little diagnostic details 7 .
To evaluate benign versus malignant characters of solid breast mass by ultrasonic imaging , attention must be paid to several imaging characteristics, rather than relying upon a single finding , such as irregular mass , polymorphous , with spicules and strongly heterogeneous echogenicity and there is attenuation of posterior echoes with acoustic shadow. In investigating breast malignancy , sonography is mainly helpful when the malignancy present as a mass 39 . In determining malignant lesions , our sensitivity , specificity , and accuracy value were 86.7% , 91.6% , and 90.6% respectively . These results correlate closely with published data of other who record ultrasound accuracy for malignancy varying from 80-90% 24,33,37,44 .

Conclusion
This study in agreement with the available literatures has revealed that real-time sonography is a simple , safe , time saving , non-invasive, useful tool for investigating breasts with palpable masses. It cause no discomfort , free of potential radiation hazards and can, therefor be repeated as often as it is necessary. Those features have led us to agree with other authors that sonography is recommended as a conventional primary tool for patients under the age of 35 years . moreover , it can be very reliably discriminate cystic from solid masses , solitary from multiple nodules , and can offer more detail about the nature of solid lumps to verify the possibility of malignant nature of these lumps. It has been found in our study that it is possible to differentiate benign from malignant masses with a high degree of accuracy considering the difficulties in differentiating benign from malignant breast lesions . Ultrasound is helpful to guide fine needle aspiration to verify nature of equivocal cases .